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This application must either be personally delivered to your county board of elections not later than the day before the election, or postmarked by a governmental postal service not later than 7th day before election day. The ballot itself must either be personally delivered to the board of elections no later than the close of polls on election day, or postmarked by a governmental postal service not later than the day before the election and received no later than the 7th day after the election. BOARD USE ONLY: Town/City/Ward/Dist: Registration No: Party: voted in office 1. I am requesting, in good faith, an absentee ballot due to (check one reason): absence from county or New York City on election day temporary illness or physical disability permanent illness or physical disability duties related to primary care of one or more individuals who are ill or physically disabled resident or patient of a Veterans Healt h Administration Hospital detention in jail / prison, awaiting trial, await ing action by a grand jury, or in prison for a convic tion of a crime or offense which was not a felony 2. absentee ballot(s) requested for the following election(s): Primary Election only General Election only Special Election only absence ends: Any election held between these dates: absence begins: 3. last name or surname first name middle initial suffix 4. date of birth county where you live phone number (optional) email (optional) 5. NY address where you live (residence) street apt city zip code state 6. street no. street name apt. city state zip code Delivery of Primary Election Ballot (check one) Deliver to me in person at the board of elections I authorize (give name): to pick up my ballot at the board of elections. Mail ballot to me at: (mailing address) 7. Delivery of General (or Special) Election Ballot (check one) Deliver to me in person at the board of elections _ I authorize (give name): to pick up my ballot at the board of elections. Mail ballot to me at: (mailing address) street no. street name apt. city state zip code Applicant Must Sign Below I certify that I am a qualified and a registered (and for primary, enrolled) voter ; and that the information in this application is true and correct and that this application will be accepted for all purposes as the equivalent of an affidavit and, if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn. Sign Here: Date 8. If applicant is unable to sign because of illness, physical disability or inability to read, the following statement must be executed: By my mark, duly witnessed hereunder, I hereby state that I am unable to sign my application for an absentee ballot without assistance because I am unable to write by reason of my illness or physical disability or because I am unable to read. I have made, or have the assistance in making, my mark in lieu of my signature. (No power of attorney or preprinted name stamps allowed. See detailed instructions.) - If applicant is unable to sign because of illness, physical disability or inability to read, the following stat ement must be executed: By my mark, duly witnessed hereunder, I hereby state that I am unable to sign my appli cation for an absentee ballot without assistance because I am unable to write by reason of my illness or physical disability or because I am unable to read. I have made, or have the assistance in making, my mark in lieu of my signature. (No power of attorney or preprinted name stamps allowed. See detailed instructions.) Date Name of Voter: Mark: I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know him or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for all purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn. - I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know him or her to be the person who affixed his or her mark to said application and understand that thi s statement will be accepted for all purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn. (signature of witness to mark) (address of witness to mark) Board Use Only 2021 Absentee Ballot Application MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY Mail to: Cayuga County Board of Elections 157 Genesee St. Basement Auburn, NY 13021 ---PAGE BREAK--- Your absentee ballot materials will be sent to you at least 32 days before federal, state, county, city or town elections in which you are eligible to vote. If you applied after this date, your ballot will be sent immediately after your completed and signed application is received and processed by your local board of elections. If you provide dates in section 2, identifying the time frame within which you will be absent from your county or from the City of New York, you will be sent a ballot for any primary, general, special election or presidential primary election which might occur during the time frame you have specified. If you prefer, you may designate someone to pick up your ballot for you, by completing the required information in section 6 and / or section 7, as appropriate. Contact your local county board of elections if you have not received your ballot.